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ot'a. ....... SAN JOAQUIN COUNTY :-<� ENVIRONMENTAL HEALTH DEPARTMENT LOP A.' :•/ 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siaov.orglehd UNIT IV .gLiF_oRai WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. Site Location 6755 East Main Street Cross Street S.Alpine Rd City Stockton zip 95215 APN 10117008 Property owner Stockton East Water Agency- Address 6767 East Main Street City Stockton zip 95215 Phone 209-948-0333 C-57 Contractor US Geological Survey Address 6000 J Street, Placer Hall City Sacramento Lic -------- Phone 916-278-3003 Consultant/Sub Cntr Address City Lic Phone Billable Party Address City Zip Phone GIS Coordinates:x 121 12 11 AW Y 37 58 05.5N (NAD 83) // Township 1 N Range 7E Section 03 CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs M WELL IDs 4 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS M MONITORING ❑ HOLLOW STEM DIA.OF BOREHOLE 18" ®MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2-Inch ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS sch 80 TYPE OF CASING: ❑STEEL R PVC ❑ OTHER _❑SOIL VAPOR PROBE IBI MUD ROTARY DEPTH OF GROUT SEAL —50' TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ®Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i a Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS 30%solids(Pure Gold) _❑OTHER: ❑OTHER: APPROX. BORING DEPTH —600' ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑ No 00 Yes:Casing Dia: 14" Casing Depth: 20' Boring Dia: 18" COMMENTS: Four,2"diameter PVC wells w/20'screens in a 18 to 9.875"borehole(see diagram)in 40'#3 sand,separated by bentonite grout. NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH of FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applicable/California Laws. Signed C1: w �>�^.lilv��, Title/Company Hydrologist/US Geological Survey Print Name Loren Metzger Date Z 3 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SIT RESS s dl-- •�0 WORK PLAN DATED l� APPLICATION ACCEPTED BY DATE ISSUED L• AREA 7 GROUT INSPECTION BY FINAL INSPECTION BY JAI �� DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUE/S`T� PR# $125 x �� C, U3 / (�/G �7 /1i SR# ro'f 53 (3500) (29 0} 02 7 J Z C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC